Adolescent Psychosocial Assessment Form
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4LIST PSYCHOLOGICAL SERVICES, PLC
ADOLESCENT PSYCHOSOCIAL ASSESSMENT
CA BC Wilder LPR SAG Center BC Washington Huron
If parent is completing, please answer for the adolescent.
GENERAL INFORMATION:
Date: ___________________ Client Name:__________________________________________ Gender:
M
F
Age:___________ Birth Date:________________________
With whom do you live?_________________________
Mother’s Full Name________________________________
Custody?
Physical
Legal
Visitation
Father’s Full Name_________________________________
Custody?
Physical
Legal
Visitation
Alternate Guardian_________________________________
Type of Guardianship?
Relative
Foster
*Did you bring a copy of the most recent court order regarding parenting time and custody?
Yes
No
Why are you seeking services at this time:______________________________________________________________
__________________________________________________________________________________________________
FAMILY HISTORY:
Who are you being raised by (check all that apply):
Biological mother
Biological father
•
Stepmother
Stepfather
Other: ___________________________________________________________
How many brothers and sisters do you have? _________________________________________________________
•
Briefly describe how you get along with others in your family (ie. Brothers, sisters, parents)_____________________
•
______________________________________________________________________________________________
______________________________________________________________________________________________
Have you ever lived away from your parents?
Yes
No If yes, explain _______________________________
•
______________________________________________________________________________________________
Is there a history of mental illness in the family?
Yes
No If yes, who and what kind of problems?_________
•
________________________________________________________________________________________________________
Have any family members committed suicide?
No
Yes, Who?_____________________________________
•
Is there a history of drug and/or alcohol problems in the family?
No
Yes, who and what kind of substance?
•
______________________________________________________________________________________________
Did you witness or experience any physical, sexual or emotional abuse? If yes, please explain.
•
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Please describe the family in which you were raised.____________________________________________________
•
Do you identify with a particular ethnic group?
Yes
No If yes, please name:___________________________
•
Do you identify with a particular religious group?
Yes
No If yes, which one:___________________________
•
Have you experienced any difficulties related to your culture, ethnicity or religious affiliation?
Yes
No
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If yes, please explain:_____________________________________________________________________________
RELATIONSHIPS:
Present relationship status:
Engaged
Boyfriend
Girlfriend
No Significant Relationship
If dating, how long with current partner? ____________________________________________
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Are you currently or have you experienced any physical, emotional, or sexual abuse in your relationship(s)? If yes,
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please explain. _________________________________________________________________________________
How many children do you have? ______ What are their ages?___________________________________________
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Do you feel you have enough good friends?
Yes
No How many do you have?________________________
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How easy do you make friends?_____________________________________________________________________
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What issues with friends are currently concerning you or your child?_______________________________________
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